What is the management of basilar artery occlusion?

Management of Basilar Artery Occlusion

For basilar artery occlusion, endovascular thrombectomy is the preferred treatment approach, especially in patients with severe neurological deficits presenting within 24 hours of symptom onset, with intravenous thrombolysis administered to eligible patients even if thrombectomy is planned. 1

Initial Assessment and Imaging

• Immediate neurovascular imaging is essential to confirm basilar artery occlusion
  • CT angiography or MR angiography should be performed urgently 1
  • Assess for ischemic core size and location of occlusion
  • Document time of symptom onset or last known well

Acute Management Algorithm

Step 1: Intravenous Thrombolysis

• Administer IV alteplase (0.9 mg/kg) to eligible patients within 4.5 hours of symptom onset 1
• Do not delay IV thrombolysis while preparing for endovascular therapy
• Recanalization rates with IV alteplase alone for basilar artery occlusion are approximately 30% 1
• Recent evidence suggests IV thrombolysis alone may produce favorable outcomes comparable to endovascular approaches in some patients 2

Step 2: Endovascular Thrombectomy

• Proceed with endovascular thrombectomy regardless of IV thrombolysis eligibility 1
• Time window extends up to 24 hours from symptom onset 3, 1
• Retrievable stents are recommended as first-choice devices 1
• For patients with basilar artery occlusions, treatment decisions should be made by a physician with stroke expertise in consultation with the neuro-interventionist 3

Step 3: If Endovascular Thrombectomy Not Available

• Consider intra-arterial thrombolysis as an alternative when:
  • Patient presents within 6 hours of symptom onset
  • Patient is not eligible for IV thrombolysis
  • Endovascular thrombectomy is not available 3
  • Case series data suggest benefit even at longer time intervals for basilar occlusion 3

Special Considerations

Anticoagulation Management

• Avoid routine reversal of anticoagulation for patients on warfarin or DOACs 3
• Endovascular thrombectomy may be considered despite anticoagulation if patients are otherwise eligible 3

Antiplatelet Therapy

• Delay aspirin administration until after the 24-hour post-thrombolysis scan has excluded intracranial hemorrhage 1

Coma and Severe Deficits

• Coma should not preclude thrombolysis or thrombectomy 4
• Even patients presenting with coma can achieve moderate outcomes (22.5% in one study) 4

Efficacy and Safety Considerations

• Symptomatic intracranial hemorrhage occurs in approximately 10% of patients treated with intra-arterial thrombolysis 1
• Recanalization is a strong predictor of survival and favorable outcomes 4
• Recent randomized trials (ATTENTION and BAOCHE) have demonstrated that endovascular therapy is beneficial for basilar artery occlusion within 24 hours of onset 5
• Factors associated with favorable outcomes include:
  • Younger age
  • Lower baseline NIHSS score
  • Less baseline ischemic changes
  • Successful recanalization 4

Treatment Pitfalls to Avoid

• Delaying treatment due to coma or severe deficits
• Waiting for clinical improvement before initiating therapy
• Limiting treatment options based solely on time from symptom onset
• Failing to prepare for endovascular therapy while administering IV thrombolysis
• Overlooking IV thrombolysis as first-line therapy even in longer time windows 2

Basilar artery occlusion remains one of the most devastating forms of stroke with high mortality and morbidity rates. Rapid assessment, early administration of IV thrombolysis when eligible, and prompt endovascular intervention offer the best chance for favorable outcomes.